1
OR Charge Capture Process Optimization
• Session 313, Friday, February15, 2019, Rajesh Selvanathan, Senior Manager,
Clinical Application, IT - Cleveland Clinic Abu Dhabi
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Rajesh Selvanathan, M.D
Has no real or apparent conflicts of interest to report.
Conflict of Interest
3
Agenda
Who we are (Cleveland Clinic Abu Dhabi)
Overview of OR Charge Process at CCAD
Problem statement, Project Plan & Governance Process
Root Cause Analysis & Solution design
Monitoring our progress
Measuring our Success
Lessons learnt
Action plan for continuous improvement
Questions
4
• Technology, people and process optimization.
• Leverage operational workflows through IT System enhancements
• Robust Training plan.
• Essence of a transition plan
• Stakeholders engagement and accountability
• Fostering a culture of open communication
Learning Objectives
5
Who We Are
• Set up the first US Multispecialty Hospital Outside North
America
• Cultivating a Sustainable Healthcare System
• Supporting the Development of Emiratis in Healthcare
A Purpose-Built Medical Campus
Diagnostic & Treatment
• 16 Procedure Rooms
• 17 Imaging Suites
• 41 Room Emergency
Department
Swing Wing
▪ Current: Office
Space
▪ Future: Supports
Bed Expansion
Ambulatory Clinic
242 Exam Rooms
Rosewood Hotel
Rosewood
Connection
Gallery Public Space
Conference Center
Critical Care 72 Beds
Acute Care 364 Beds
409,234 m2 total gross
area on a 23 acre site
364 beds scalable to
496 beds
26 Operating Rooms
1st LEED Gold
certified hospital in the
GCC
OR Charge Process: Overview
Procedure
ordered
Preference Card
assigned
Supplies pick list for day
of surgery
Lawson Inventory
management
Material Mgt. Interface
Epic OpTime module
OR documentation done by nursing,
Surgeon and Anesthesia on OR log
including charging elements
All Surgical charges including
room, procedure,
supply/implants, Anesthesia,
medication etc.. Are verified by
the OR charge nurse
Surgical Log is posted and this
drops the charges to the Epic HB
module
Charges reviewed/modified by
the RI and coding team and
claim is processed.
OR Inventory Location
8
Local Problem
Issues:
74% of OR case logs were not posted in under 30 days in the first nine
months of opening, resulting in a potential loss of revenue up to 70%
Impact:
Potential loss of revenue up to 70%
Negative patient experience due to not being able to produce a final bill
Inefficient process causing waste of both supplies and personnel utilization
9
Overview of Open OR Cases
1
st
Apr to 30
th
Sept
2015
10
Project Goals & Objectives
Primary Objective: Eliminate root causes for delay in log posting
and reduce percentage of open logs from > 70% to < 5% within a year
Other Objectives:
• Reduce turnaround time for log posting from average 36 days to < 2
days
• Develop an integrated OR Technical Charging process, to allow for
effective charge capturing/claim submission for revenue reimbursement
• Implement effective monitoring mechanisms
Project Plan
Monitor and Control
Daily monitoring of progress through reports and caregiver feedback Evaluate enhancement requests, follow change process and deploy changes
Design and Implement
Implement Action plan to resolve root cause
Solution designing
Workflow optimization, process mapping
improvements
Implement operational process changes
IT changes, Training & Deployment in production
Analyze, Measure, Define
Formation of Project team under guidance of Steering committee.
Establish Operational and Clinical governance structure and process
Analyzing workflows.
Understanding Industry best practices
Identifying problem areas and root causes
Define Problem statement and develop action plan to address root causes
SEP OCT
NOV
DEC
JAN
FEB
MAR
APR MAY JUN JUL
AUG
SEP OCT
NOV
DEC
Define
Measure
Analyze
Improve Monitor & Control
2015 2016
Project Sponsors and Team
Chief Operating Office
Chief Information Office
Chief Nursing Office
Executive
Sponsors
Institute
Administrator
Director Nursing-
Perioperative
services
Chief Medical
Informatics Office
Supply Chain
Supply Chain
managers
Category
managers
Warehouse
managers
Peri-op Nursing services
Asst. Nurse
Managers
OR Nurse
managers
Intra-op Nurses
OR Charge
poster
Information Technology
Sr. Manager
OpTime
OpTime Analyst
Lawson IT
Analyst
Informatics
Trainer
Executive Director,
Clinical applications
Continuous Improvement
Sr. Continuous
Improvement
Manager
CSSD Manager
OR Pref. Card
Manager
Steering
Committee
Project Team
Continuous
Improvement
Analyst
Chief Administrative
Office
Executive director,
Clinical Operations
Senior
specialist &
ERP
Amb and Inp
nurse
managers
OR Technicians
Project Governance
Process mapping,
piloting and
implementing
Daily
/Weekly
Workshops
Analysis
Solution design
and RCA
Deployment in production
Project Team
Build and testing in
POC & TST
Caregiver training
(IT Changes and Process)
Endorsed by steering committee
Process Changes
IT changes
Steering Committee
iCAG approval
process
Process and Policy
committee
approval
Operational and Clinical governance
Daily
reports to
working
groups
Interface
Errors
Daily log
reviews
Feedback
from
nursing
IT visual
dashboards
Monitoring
our success
Fortnightly status report
Analyze, Define and Measure
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High level Root Cause Analysis
Inaccurate
Implant
Charge
capture
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Prioritizing Root Causes
• From our analysis session, it was evident that IT intervention and
process optimization was needed to fix existing issues
• Top Root Causes:
• Zero cost items (Supplies and Implants)
• Items without HCPCS codes
• Items which were not bought at CCAD were available for documentation (Free of cost, or bought
by bypassing our Supply chain)
• Incomplete or incorrect Preference cards
• Supply categorization
• Cancelled logs due to early opening of logs even before patient arrived in hospital
• OpenAnesthesia encounter or incomplete documentation
Analysis: Detailed Pareto chart showing 35 different root
causes
0
20
40
60
80
100
120
0
20
40
60
80
100
120
140
Count
(Open Cases)
Cumulative %
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Measure & Define: Baseline Data
Key metrics captured as baseline data at the start
of project (Oct 2015):
• Average Turnaround time for Log posting – 36 days
• Potential uncharged revenue up to 70%
• Total unposted cases - 1166/1570
Improve: Action Plan
Dedicated time was slotted across all required teams for better traction
Workgroup meetings were conducted every week with follow-up actions
for each teams clearly identified
Defined timelines for tasks and strict adherence to governance process
followed
Coordination of interdependent tasks with specific leads assigned
Each team needed to provide updates on the tasks In Progress &
Completed
Centralized tracker for all open action items and status updates for
visibility followed
When required, smaller task forces were formed and action items were
assigned
Fortnightly updates to steering committee provided on progress
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Solution Design Plan
Project
Success
People
New Role created for Charge
poster
Replacement of retiring or leaving
caregivers
Training of new caregivers
Process
Standard workflows created
Updated Operating Manuals
Technology
IT System enhancements to
meet compliance and regional
needs
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People - Improvements
Opportunities Solutions Impact
No existing charge poster – was done
by OR Manager
New position created and caregiver
hired for charge posting
Faster and accurate posting of logs
Stewardship and succession planning
across all functions
Create culture that incorporates cross
development of staff to act as backups
for all key functions
Better prepared to overcome
challenges faced by key people
leaving
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Technology - Lawson IT system improvements
Opportunities Fix Impact
Missing HCPCS code Revenue Integrity team generated HCPCS
codes for all items missing them (6816 items)
Report sent out weekly to revenue integrity
from Epic to monitor missing HCPCS codes
Claims were no longer rejected on
basis of missing HCPCS codes
Zero cost and Inactive items available in
Epic
Lawson - Epic interface enhanced to stop
Inactive and zero cost items being sent over to
Epic on nightly basis
Claims
no longer rejected on basis
of inactive or zero cost items
Supply chain ensured alignment
with system list
Items turning zero cost after stock
reaches zero
System patch applied in Lawson to stop this
from happening
Items no longer with zero cost for
stock zero
Pharmaceutical supplies missing “GRC
codes” required for billing purpose
GRC codes updated in system Pharmaceutical items included in
claims
Categorization of items into Supplies and
Implants
Review committee formed led by the Nursing
manager to differentiate ‘Implants’ (Prefix IM
given in type in system) from ‘Supplies’
Meet documentation compliance
to ensure requirements for claims
submission
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Technology – Epic Improvements (1)
Opportunities Fix Impact
Incorrect or Incomplete Preference Card Updated ‘supplies pick list’ in preference cards
for surgical specialties
Missing medications for intra-op identified and
built in Epic
Easier, faster and more complete
documentation of items
Cancelled cases for No shows Hard Stop built to eliminate opening of Cases
by the OR Nurses prior to the arrival of
patients
No opened logs for cases in error
prior to patient arrival
Missing Procedure Cards New 73 procedure cards built Easier, faster and more complete
documentation of items
Missing Procedures and CPT codes 27 new procedures built with associated CPT
codes
Correct charging and coding for
procedures performed
Incomplete Anesthesia documentation Inbasket messaging to Anesthesiologists for
open encounters
Report sent out to Chiefs for Open encounters
Prompt for documentation
completion and faster turnaround
for Billing with complete
documentation
Ambiguity of supply location while
picking supplies
Added the location column to pick list report for
easier picking
Accurate and efficient picking of
supplies for day of surgery
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Technology – Epic Improvements (2)
Procedure card updated to reflect all supplies required.
Inventory Location added to pick list for accuracy and convenience
Log opening warning to prevent nurses from opening logs before
patient arrival.
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People - Training
Opportunities Fix Impact
Training for the new role of OR charge
poster and existing/new Peri-op nurses
Identified and defined new workflows
as per scope of practice
Trained OR charge posters to review
surgical charges and Peri-op nurses
to document surgical charges
appropriately
Current system improvements not
reflected in Epic training environment
for Peri-op nurses and
Anesthesiologists
Epic changes in relation to project
reflected in existing Epic training
material
Up to date training material ensure
knowledge base for processes and
functionality
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Process Improvements - General
Opportunities Fix Impact
No Operating Manuals for Material
Managements
Developed operating manual for OR
Material Management, establishing
strong communication channels
Clear and defined process published
for new and existing caregivers
No workflow for Intra-op nurse to
add/substitute item in Preference card
New workflow designed for Intra-op
nurse to request changes in Preference
card from Intra-op navigator
Process improvements through easier
addition of items to Preference cards
Substitute items enable Procedure
cards
Nurse Managers trained on Process for
Global substitution of supplies charge
capture
Easier and complete substitution of
items across specialties
Communication Vocera/email group optimization with
supply chain member and OR
technicians mapped to peri-op service
area
Easier and defined communication
channels
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Process Improvements – Material Management
Opportunities Fix Impact
Variances in Inventory (Physical vs
System)
Cleared back-log related invoices worth
2.5 million
Implemented a continuous cycle count
process for OR inventory and a
returned supplies process
Balancing of books
Helped understand usage and return of
stocks
Manual inventory depletion from
Lawson leading to delay and incorrect
counts
Implemented auto-depletion interface
from Epic to Lawson for accurate stock
inventory
Faster and more accurate count
matching at end of day
OR inventory and supply chain location Set-
up specialized OR KANBANs and a
two bin Perpetual store to segregate
the supplies > AED183
Ensured supplies are readily available
and issued by distribution center with
required labels essential for charge
capture
Process gaps in consignment, free of
charge and management of sample
supplies
Addressed process gaps by developing
policies
Accurate capture of charges for these
supplies
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Monitoring Progress Towards Success
New Dashboards within Epic for preference
card management and update tracking
A weekly report to look for zero cost items
and ones with missing HCPCS
A Tableau dashboard to monitor Open
cases and root causes
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Monitoring Progress Towards Success
New Dashboards within Epic for preference card management
and update tracking
To ensure regular review and updating supplies
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Monitoring Progress Towards Success
Tableau Dashboard, providing a holistic view of:
Posted vs Unposted cases with revenue per surgical service
Cause of the unposted cases
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Measuring our Success
Value Derived – Turnaround Time for Log Posting
The Log posting turnaround went down from average 36 days to 1 day (excluding
weekends and holidays)
0
10
20
30
40
Q2 2015
Q3 2015
Q4 2015
Q1 2016
Q2 2016
Q3 2017
Q4 2016
Q1 2017
Q2 2017
Q3 2017
Q4 2017
Q1 2018
Q2 2018
Log posting TAT
Log posting TAT
Volume of OR Cases - Actual Volumes per Quarter 2015-2018
404
1030
1872
2387
2430
2250
2856
3354
3240
3439
3883
4323
3898
1578
299
762
1385
1766
1798
1665
2113
2482
2398
2545
2873
3199
2885
1168
0
500
1000
1500
2000
2500
3000
3500
4000
4500
5000
Q2
2015
Q3
2015
Q4
2015
Q1
2016
Q2
2016
Q3
2016
Q4
2016
Q1
2017
Q2
2017
Q3
2017
Q4
2017
Q1
2018
Q2
2018
Q3
2018
Actual volumes vs. Potential Impact trend
Actual OR Volumes Potential Unposted Logs
This graph shows the growing OR volumes overtime and the potential magnitude of unposted logs if
IT interventions were not implemented
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Item Master Clean Up
0
500
1,000
1,500
2,000
2,500
Number of
items Active
To Inactive
Stock To
Non-Stock
Manufacture
Details
Pack Factor Non-Stock
To Stock
Item master clean up
Number of changes
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Overall Improvements
Reduced the charge posting time
System Integration optimized
Material Master list clean-up completed
Procedure card reviewed
New Role for Peri-op coder was recruited.
Allowed us to increase surgical volumes
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Lessons Learned
Process
Robust training is critical
for continuous improvement
Transition plan essential for
retiring caregivers and role
changes
People
Change Management &
Accountability for existing
workflow problems challenges
Open communication
encourage dialogue for
positive change
Technology
Active feedback from ‘on the
ground caregivers’ for IT System
enhancements.
Health IT solutions designed to
leverage operational workflows
will influence positive outcomes
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Action Plan for Continuous Improvement
2 way integration between Lawson and Epic
Pilot implementation of GS1 barcoded supplies and Implants
Epic build for Implant sets
Epic and OR Nursing Managers continue effort of bundling procedure cards to
minimize return of supplies as the pick lists will be more relevant
Activate ‘Replace/Substitute’ functionality in Lawson.
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Summary Recap
Problem Statement: Recurring existence of unposted OR cases being more
than 70%, primarily due to the long turnaround time for log posting that impact timely
reimbursement for cases performed
Solution Design and Implementation: System enhancements in Epic
and Lawson, in addition to process changes and training opportunities
Result:
Reduced turnaround time for log posting
Significantly reduced unposted OR cases by >60%
Improved revenue growth related to OR cases.
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Name
Discipline
Title
Department
Inas
AlKhatib
Continuous Improvement
Sr. Continuous Improvement Manager
Executive Administration
Betty Kho
Clinical and Nursing
Nurse Manager, OR
Clinical and Nursing
Cherrysse Downton
Clinical and Nursing
Nurse Manager, OR
Clinical and Nursing
Edith Jonkman
Clinical and Nursing
Assistant Nurse Manager, Periop
Clinical and Nursing
Michelle Park
Clinical and Nursing
Assistant Nurse Manager, Periop
Clinical and Nursing
Darren Parry
Clinical and Nursing
Sr. Nurse Manager, OR
Clinical and Nursing
Judy Pearce
Clinical and Nursing
Executive Clinical Director, Acute and Critical Care
Clinical and Nursing
Marie Murray
Clinical and Nursing
Executive Clinical Director, Acute Care
Clinical and Nursing
Maria Magat
Clinical and Nursing
Staff Nurse, Perioperative Coder Coordinator
Clinical and Nursing
Margaret Hartman
Clinical and Nursing
OR Business Manager
Clinical and Nursing
Juliet Rocha
Clinical and Nursing
Manager, EP Lab/Cath intervention
Clinical and Nursing
Jennifer Loucks
Clinical and Nursing
Staff Nurse, OR
Clinical and Nursing
Jennifer Loucks
Clinical and Nursing
Staff Nurse, OR
Clinical and Nursing
Linda Greaney
Clinical and Nursing
Staff Nurse, OR
Clinical and Nursing
Paula Sheena Paguia
Clinical and Nursing
Staff Nurse, Ambulatory
Clinical and Nursing
Maryam Abdi
Clinical and Nursing
Sr. Health Unit Coordinator, Ambulatory
Clinical and Nursing
Jeffrey Larson
Clinical and Nursing
EP Lab, Cath Intervention Technician
Clinical and Nursing
Carrie A Richardson
Clinical and Nursing
Nurse Manager, Endoscopy/Procedures
Clinical and Nursing
Jurate Hegarty
Clinical and Nursing
Assistant Nurse Manager, Periop
Clinical and Nursing
Sheila Ann Burns
Clinical and Nursing
Senior Manager, Case Management
Clinical and Nursing
Kelley Thornton
Clinical and Nursing
Assistant Nurse Manager, PACU/prep
Clinical and Nursing
Cynthia Edgelow
Clinical and Nursing
Nurse Manager, Ambulatory
Clinical and Nursing
Rachel Rowson
Clinical and Nursing
Nurse Manager, Acute Care
Clinical and Nursing
Diane Powell
Clinical and Nursing
Nurse Manager, PACU
Clinical and Nursing
Nuno Raposo
Clinical and Nursing
Perfusionist, Clinical and Nursing
Clinical and Nursing
Lea Melo
Clinical and Nursing
Health Unit Coordinator, Critical Care
Clinical and Nursing
Vivienne Breault
Clinical and Nursing
Perioperative Staff Nurse
Clinical and Nursing
Ralph Jean Mary
Medical
Institute, Department Administrator, Medical
Medical
Dee Eadie
Medical
Institute, Department Administrator, Medical
Medical
Roba Ghanayem
Medical
Institute, Department Administrator, Medical
Medical
Basheer Veleri
Medical
Operating Room Tech
Medical
Jason Unger
Medical
Manager, Sterile Processing
Medical
Project Team Members
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Name
Discipline
Title
Department
Ela
Gredig
Medical
Inventory Processor, Operations
Medical
Madeleine Mabini
Medical
Surgical Coordinator, Medical
Medical
Marwan Atrouni
Medical
Physician
Medical
Melissa LiNg
Medical
Physician
Anesthesiology Institute
Amira Siyam
Medical
Physician
Anaesthesiology
Institute
Markus Haisjackl
Medical
Physician
Anaesthesiology
Institute
Massimo Ferrigno
Medical
Chief,
Anaesthesiology Institute, Medical
Anaesthesiology
Institute
Philip Anderson
Medical
Lead Anesthesia, Respiratory Technician, Medical
Anaesthesiology
Institute
Eric Matayoshi
Medical
Department Chair, General Surgery, Medical
General Surgery
Khalid Almuti
Medical
Section Head, Electrophysiology, Medical
Heart and Vascular Institute
Amit Asopa
Medical
Physician
Heart and Vascular Institute
Waleed Hassen
Medical
Physician
Surgical Subspecialty
Jason Usher
Information Technology
Epic Clarity Analyst, Info. Technology
Information Technology
Michelle Machon
Clinical Informatics
Director, Clinical Informatics
Information Technology
Makarand Rogiye
Clinical Applications
Senior Application Analyst, Info Technology
Information Technology
Rajesh Selvanathan
Clinical Applications
Senior Manager, Clinical Applications, Info Technology
Information Technology
Ajaypal Atwal
Clinical Informatics
Informatics Trainer, Info Technology
Information Technology
Vicente DeGuzman
Information Technology
Lawson SCM Analyst, Info Technology
Information Technology
Durairaj
Dhamodaran
Business Applications
Supply Chain Analyst, Info Technology
Information Technology
Jithin Nambiar
Information Technology
Application Analyst II, Info Technology
Information Technology
Yagya Datt
Information Technology
Senior Integration Engineer, Info Technology
Information Technology
Azfar Agha
Information Technology
Senior PACS Admin, Info Technology
Information Technology
Benjamin Joyce
Information Technology
Epic Orders & ClinDoc SSO Analyst, Info Technology
Information Technology
Kumar Rangaraj
Information Technology
Surgical and Procedure Analyst, Info Technology
Information Technology
Karuna Ram
Clinical Applications
Senior Manager, Clinical Applications
Information Technology
Crystal Priebe
Clinical Informatics
Informatics Trainer, Info Technology
Information Technology
John Lindsay
Clinical Informatics
Informatics Trainer, Info Technology
Information Technology
Bob Thomas
Unified Cisco Network
Vocera System Administrator, Info Technology
Information Technology
Albin Abraham
Finance
Senior Revenue Integrity Analyst, Finance
Finance
Philip Lieffers
Finance
Decision Support Analyst, Finance
Finance
Maria Carreno
Patient Financial Services
Manager, Revenue Integrity
Revenue Cycle Management
Bashaier Ballool
Patient Financial Services
Sr. Revenue Integrity Specialist
Revenue Cycle Management
Project Team Members
41
Name
Discipline
Title
Department
Fatima Al Shamsi
Patient Financial Services
Sr. Revenue Integrity Specialist
Revenue Cycle Management
Raymond Berry
Patient Financial Services
Director, Patient Financial Services
Revenue Cycle Management
Hussam Alfakieh
Alkourdi
Patient Financial Services
Senior Manager, Billing and Recovery
Revenue Cycle Management
Joshua Snowden
Patient Financial Services
Manager, Payer Network, Contracting and Pricing
Revenue Cycle Management
Shelia Schardein
HIMS
Senior Manager, Clinical Coding
Revenue Cycle Management
Rhay Gatbonton
HIMS
Sr. Coding Team Lead
Revenue Cycle Management
David McNamara
Logistics
Directors, Logistics
Supply Chain Management
Shaista Sait
SCM Business Application
Manager, Supply Chain Business Applications
Supply Chain Management
Jan Ilagan
Operations
Sr. Supply Chain Data Analyst, Operations
Supply Chain Management
Essa Al Hertani
SCM Business Application
Senior Specialist, ERP and Master Files, Operations
Supply Chain Management
Sara Hutt
Operations
Director, Planning, Operations
Supply Chain Management
Hashid Kalappurath
Operations
Category Manager
Supply Chain Management
Ashraf Urothiyil
Operations
Category Manager
Supply Chain Management
Sameena Buddha
Operations
Category Manager
Supply Chain Management
Belal Zuaiter
Operations
Category Manager
Supply Chain Management
Satheesh Nair
Operations
Category Manager
Supply Chain Management
Sivaraj
Pitchaipazham
Operations
Category Manager
Supply Chain Management
Jonathan Caller
Operations
Manager, HVAC Controls, Operations
Facilities Operations and
Maintenance
Parvathy Kumar
International Mobility
Senior Manager, International Mobility
Human Capital
Project Team Members
